Dr. Merrilee Fullerton on Healthcare

Well, politics and the dreadful, desperate life that is drug addiction are several planets apart. Insite at least gets some drug addicts who happen to live in the Vancouver downtown a safe haven where they can come and find health care professionals who start by accepting them where they are at the time, physically, emotionally and in other ways make a kind of contact with them that may be a springboard to a desire to improve their own lives. Then ,if treatment is something they want they have a respected professional to help them get started.

All the politics in the world will not help to get drug use lessened if the needs of the individuals as people are not addressed one by one. The greatest benefit of Insite is not the needle exchange or the reduction of the risk of transmission of blood-borne diseases but the respect shown to those individuals by the provision of a service and professionals who meet the needs of the patients at the time and place in their addiction where they are.

the greatest benefit of Insite may be that it highlights the inadequacies of today's treatment programs......the debate over the ethics of Insite will perhaps have a silver lining if more treatment programs for addiction and more mental health resources develop as a result....the ethics behind the "harm reduction" process will always be up for debate.

from Donald Hedges:

http://www.theglobeandmail.com/servlet/story/LAC.20080825.COLETTS25-11/TPStory/?query=donald+hedges

R:

Breaking down the InSite issue is an excellent review of our politicla health care beast. Use this BC example and watch it unfold in Ontario.

Traditional care for addiction had been static -people were getting helped, but because it is a horrific situation new options were needed. In rolls Federal money, to push a new political agenda.

In remains debatable how good InSite is but since the "system" wants guidelines to function, it is best to have a single set to follow - thus InSite, which has other baggage on a federal level, must go.

We have leaders and teams that have to make decisions about what directions are best for us.

Transpose this to Ontario (and it will because this is how central thinks), and you will soon see the beauty of LHINs assigning which services go where based on political needs and whims, and how independant services must be killed off. This adds pressure to the need to kill off the FFS groups, who still have capacity to buck against guideline based practice.


Everyone's back to work next week so stuff will start coming out soon.

The plan is good.

This is not about selecting treatment over harm-reduction! It has to be about both. Diverting the $ for the latter towards treatment would buy little of the former in fact.

The folks who use harm reduction sites tend to be those for whom treatment (if funded as needed) is often not a current option. Many have been through treatment periods but return to the demons. Has anyone looked at the success rate of drug treatment? Has anyone looked at the typical cycle leading to success for those that do come around?

Semi Rural has it right in my estimation. Maintain respect based contact with this vulerable population and facilitate as much movement toward treatment as can be mustered.

Addiction has to be understood as a set of behaviours as well as a set of unhealthy chemical reactions. In my experience, people tend to not end one behaviour without substituting for it with something else...hopefully more positive.

Harm reduction site staffunderstand this and attempt to influence behaviour toward improved functioning. The alternative is not treatment; that is too simplistic and the sort of morality based reasoning certain among us are attracted to.

What happens whe abortion is criminalized? The vistims are driven fully underground for their needs. Same with drug abuse.

The housing needs of the drug addicted have to be dealt with at least as badly as the conventional treatment needs they have. Without stable shelter the treated drift back into life styles that pose risk for them.

Ahh but the beuaty of politics, particularly in health, is that is not about the most compassionate, or even compentent care. It is how politicians wish to distribute taxes resources.

There are great arguements that harm reduction policies can impact on a proportion of society that can not get itself out of a tragic situation, but it attracts huge political pressure, in that some view this as self indulgent behavior not worthy of tax support. Politically, the current federal government wishes to respond to that pressure. More small marginal groups thown under the bus.

Coming soon in Ontario will be the new lists of how and where care be obtained through our new single queue system. Be grateful that you're not in a marginal group - catering to the massses is about to hit full stride. Elections only 4 years of for the Ontraio Liberals.

The Ottawa Citizen

Tuesday, August 26, 2008
Health officials in Eastern Ontario are poised to do away with the
traditional practice of having family doctors refer patients to specific
specialists for surgery, in favour of a centralized system that could
shorten waiting lists.

Officials are weighing the merits of a single-queue system as a partial cure
for the region, which remains dead last in most of the five
government-monitored wait-times categories: cataract surgery, cardiac
surgery, cancer care, diagnostic scans and joint replacements.

MFO

I do agree with you on this one. The politics of appearing to stick it to the morally weak among us is frequently resorted to. I comfort myself with the thought that there is a special place in hell for the sort that promote this #%@&.

Ahh but HH:

It isn't only the "morally weak", it's all the marginal groups that haven't got the voice to survive.

That is the extreme problem that central is constantly dealing with - how to effectively ration. Many meetings are held on how to treat these marginal annoying groups who want things.

The great unfair nature of Ontario's health sytem is that it allows no way out, since "out of pocket" buyout isn't allowed for essential services. that decision process is the same one that punishes those who are "morally weak".

There is rising evidence that central truly does believe it knows what best for all of us - and will use our money to make sure we get what they believe we need. InSite is just a small example of what will come.

Heck - it's just politics.

Marginal groups are a slippery slope - but we are talking about the Ontario Liberal party here, so expect a few million allocated towards enhanced addiction services (as long as the spotlight remains).

But the spotlight will fade as money is spent, and little, if any progress is made, and new causes emerge.

Good news about that centralized referral system though - technology can make a difference! (I wonder how much it will cost?)

And MFO, fix that spelling!

Must say that I'm burned out where compassion for drug addiction is concerned...spent enough time in the field in my psychiatric days and then in comprehensive Family Practice...the constant attempts at manipulation, the tremendous amount of psychopathology and personality disorders which are,essentially, untreatable just grinds one down....so much of it is a form of 'voluntary insanity'...McNaughton Rules should not apply to those who voluntarily choose to become temporarily insane.

'Harm reduction' should reduce the innumerable 'harms' that result from addiction...I don't think that there's enough money in the pot to counter the harm being carried out by addicts to themselves, their loved ones and the rest of society.

Perhaps it would be cheaper, more effective with less harm occurring to all concerned if a facility was built on Baffin Island with its clients going 'cold turkey' and then remain there for the year until the ice breaks and the next ship comes in with its load of clients.

As I said, I got burned out in the field.

Well Andris, I can understand your frustrations. Clearly in a compassionate society we keep trying. Maybe we are the ones who should be going to Baffin Island....just had some friends going to Manitoulin Island....they say it is tranquil and peaceful and maybe exactly what the doctor ordered.

I'll be changing the thread shortly to discuss the Champlain LHINs plan for central queuing which just makes me wonder what kind of thinking is going into the 'transformation' and what kind of deal is being made in exchange for this little change. Me thinks there is some bartering going on somewhere. Perhaps central queuing (which doesn't make much sense if you really think about it) in exchange for more funding! Could very well be.

I think someone at the Champlain LHIN has read "The Goal" by Eli Goldratt and wants to experiment.

The Goal is a 'business novel' set in an industrial organization that coaches managers on how to identify bottlenecks (in this case access to care) and exploit them by re-arranging the peripheral system to maximize the organization's overall goal.

It will be interesting to see if the vested interests are prepared to come to the table.

Coming back from the summer:

Just an update as we start coming back in to central next week.

Everything is quite stable - all the hospitals missing CEOs are behaving, the LHINs are getting the hang of things, and the new Minister is being properly trained. It looks like the 3rd quarter of the year will be fine.

Some realities:

Although no panic is setting in, the budget is in trouble with what appears to be a prolonged slowdown. The billion given away this week is no big news but helps serve to boost the local economies up a bit. It actually is somewhat funny that all that is being done is returning on a per capita basis, tax money that was pulled out. It a real arguement for increasing local taxing authority. Health will be more openly giving out resources based on per capita formulas

It is considered unlikely that Management Board will provide any new money this year. That has relevance for the signing of a contract.

The increased allowed to the OHIP is fixed at about 4% and that's the global increase. Some of that is for favoured things - some, up to the OMA internal process. A wet paper bag could have got at least 3% if a contract was signed in April as it matched the teacher's increase. Time have changed so it will be interesting to see what the final increase to the pool is 2, 3, or 4%. A lot of rumour that 2.5% is looking generous. It is expected to be all signed off by end of November at the latest. Four years will get us past the next elction.

We are already setting the budgets for 2009-10 and it's tighter. Many outside of the government don't understand that the next year budget is fixed in the fall of the previous year, so delaying negogiations out to signature in November is a style that the government loves because the next years budget is already fixed before the contract is signed - thus it is already known what the "cap" in dealing is.

Nothing sneaky in the contract. It will be clear and pass fast - so many physicians are secure that the boat won't be rocked by the majority even with a limted increase. Everyone knows that it won't fly in public for a big increase at all.

Public Relations - expecting PR on both sides to heat up a bit - too few doctors - we've increased dramatically the medical school spots and we have new records of physicians getting licenses; waiting lists - we've tackled those and shown real improvement with the big 8; access to care - ED are open and seeing patients. Access to specialized care - with the increase in regional centres coming through the LHIns we anticipate higher access to specilaized care.

All in all it's good times with the plans central has developed and we expect a good remaining year.

ELB: Whoever read "The Goal" needs to get current. It's old news, at least 10 or more years. It won't help, and I know of at least one concrete example where it was applied in the hospital sector and suffered from lack of implementation savvy. Big mess. But the CEO got a big settlement.

As for central queuing for specialist referrals,my guys will have nothing to do with this. They all know specialists they wouldn't refer their worst enemy to. They work with the folks they know and who know them. So, a referral is trusted when it comes from here, and so is the result. I predict that the more Central tries to create the standardized "database" state, the more creative the professionals will become in circumventing it. Even some specialists graduated at the bottom of the class.

Last, as for the Champlain LHIN. CHEO considers itself at least a national if not an international referral centre. So, as we have always done in cases where paediatric psychiatry is non-existent, we referred a kid who really needed help. Some desk person phoned up and said they were not supposed to take referrals from outside their LHIN. "So why are they fundraising down here, then?" I asked. There was no response.

So, Central, go for it!!

'They all know specialists they wouldn't refer their worst enemy to' -Big Bad

So, I ask, what are your guys doing about these incompetents in their midst? Looking the other way can't be the ethical thing to be doing if that be the case.

While I do understand their unwillingness to place their patients in a bad situation it is beyond me that they willingly let others wonder innocently into a mess. I guess that's business;let's move along.

Perhaps it's time to start tracking patient satisfaction levels for physicians centrally as is now done with schools and hospitals. Docs getting bad numbers can appeal their lot and explain the conspiracy theories they have leading to possible adjudicated adjustments...or not. Seems to me this would be a minimum protection within a system going more privately based.

While I am at it, how about requiring all senior medical executives dispensing or taking public $ to be licensed? A 'college' would be a nice tool to have in place to deal with the worst scenarios that come to light.

Just asking.

Central queue - let's reflect on this for a second.
---------------------------
Who selects the patient to be queued? Does a central screening approve entry intothe queuing? Or is this the primary care provider saying "This person may need surgery for a queuable condition" adequate for entry into the queue?

In which case, does the referral for assessment for surgery become part of the queue? Or is that after surgical assessment confirming the need for the queable procedure.

Who accepts vicarious liability whiile in the queue?

Is the "surgeon" obliged to automatically accept the referrals from the queue?

When does responsibility for the intervention begin,before or after being queued?

Or after beeing seen and put on a queue?

In which case, does the surgeon pass it on to the surgeon with the shortest queue?

For those conditions that will be centrally queued (managed), will this also manage the engendered follow up?

Or does that also go back into the queue?

Or does that follow up go back to possibly local surgeon closer to home?

Is that surgeon obliged to accept such responsibility?

Let's say a patient is referred for a condition that is be centrally managed in a queue. The patient then decides the now centrally defined available queue waiting time is unacceptable or is longer than another case referred after their own, what recourse is available? Does the p[atinet forgo any rights by accepting to be queued?

If a patient declines to be queued to Dr X, is an alernative mutually acceptable arrangement transferrable to another provider?

Is the patient still covered under OHIP for a queuable service is it automatically deemed to be a medically necessary service, even if declined or obtained outside of the queue?

Is the act of queuing considered to be medical advice regarding appropriateness of care and location of care?

HH: As for our own methods of physician recruitment, it's a small club. The best we can do for ourselves is, when building our practices, to go by references we know and trust about prospective colleagues. Word gets around about circumstances to avoid. We just avoided two -- inspite of considerable external pressure.

Oh, and, by the way, HH, there is a Rate-A-Doc system on the web for Ontario docs. It makes for interesting reading sometimes.

BBA,

Thanks for your comment...never said 'The Goal' was right for health care. It just sounds like this central queueing notion was lifted out of some advice from 'Jonah'.

MFO, is that a 4 percent increase over the LIFETIME of the 2008-2012 contract, or just the increase for the first year?

And do your numbers include increased usage? Don't forget one of George's promises - reduce the number of 'orphan' patients.

eklimek,

The questions you ask are all reasonable and stem from an ever expanding intervention of central control by government into the patient/physician relationship.

It would seem to me that the specialist responsibility for monitoring patients in the queue will be alleviated while more responsibility will fall on the family doctor (or god knows what other provider!) to monitor the patient while in the central queue.

The whole thing is kind of Monty Pythonesque when one considers that the fine art of queuing and all that it entails is result of a rationed system looking desperately for any kind of solution of optics regardless of how silly it seems.

Perhaps we can have a new Ministry....the Ministry of Silly Queues....nahhh, it doesn't have the right ring to it.

However, it has been postulated that all doctors should be trained in the management of wait times.

Tells me a lot about where our "greatest health care system in the world is going".

On a more positive note, we should be watching what Sweden has done in health care to bring down wait times...including co-payments or user fees with a ceiling and private hospitals for those who would rather use them.

As for the shortage of providers, it will improve with the new doctors in the pipeline and with the new providers the government is touting...enough so that more private provision will not substantially decrease access in the public sector.

I believe government knows this or it would not be producing so many providers that it wouldn't be able to afford otherwise.

Just my take of course...and what do I know after all.

HH, all I can say to your comments is that more regulation will likely drive up costs.

As for some preferred physicians in the referral process, this often has more to do with their bedside manner than anything else and with their ability to make themselves available to the family doctor if the patient should be deteriorating in some way.

Surgical outcomes are affected by many things including the health of the patient in the first place, the type of patients the hospital draws to it and even the geographic location..ie inner city or not.

There is a minimum standard for licensing of surgeons just like most other professions which does not make those surgeons with less expertise than others incompetent, it just means there is a variation of skill within an accepted standard.

Queues and rationing

If Roscoe Cataract is queued to Dr I.M. Soslow and finds he can "get'er done" by Dr I. Balsarus in less time, does he flash the rationing Q card? i.e. does the Q card entitle Roscoe only to Q care, or any care?

And if I. Balsarus suggests the newfangled implantable refractive corrective lens so that "Roscoe don't need no more glsses", will Bill 8 be enforced and a penalty under law apply?

It seems to make sense that, for the queue system to work, ALL patients and specialists must participate, and the system does the matching, regardless of the patient or specialist wishes.

Is that likely to be acceptable to all parties - I think not.

Be aware, we may soon find ourselves with a new queue of orphan patients - I'll bet the patients won't be too selective - but the FPs are another story!

There are other mechanisms of shortening wait times, including a system where consultants put on short term "pushes" to clear back lists. This requires a coordinated effort from the insitution in terms of resources (office space, staff overtime, procedure rooms etc). It does need a clear committment from all concerned. The problem with a Queue system is that all that is accompluished is the establishment of a queue.

Tragically, you don't seem to like family practitioners much. It's their job to be advocates for their patients. Our docs are not processing widgets here (which is what they teach us in business school).

In the referral game, one reason a good doc want to know who he/she are referring to is to ensure an optimal outcome for the patients. If I get your drift, you seem to be suggesting that equity demands that everyone shares in the risk of sub-optimal outcomes.

Somehow I just can't feel good about the free eye exam I had last week being at the cost of someone who experienced a sub-optimal outcome or died of c-difficile just so I could be processed for health care in an equitable manner.

BBA I LOVE family practitioners - they are the much-maligned cornerstone of our public health system.

I AM critical, however, of the capitated form of FP compensation, in its current form. I believe it could be much better, such that there would be no disincentive to enroll ANY patient, and negation would be a thing of the past.

But it would be an all or nothing proposition - every individual receiving public health care in the province must be 'attached' to an FP (or maybe NP, PA, whatever) as the gateway to the system. And the FP (or FP group as the case may be) would be appropriately compensated for that additional responsibility.

TOhipster,

That is the system France uses but it also has Smart cards.

Trouble with every patient having to be rostered to a provider is that there aren't enough physicians. The government must know that. And even if by default the patient was rostered to an NP, there would still need to be a responsible physician involved...unless of course you believe that an NP is equivalent to a family doctor which just isn't the case.

So is that (a lack of FPs) the only problem with making it work? I see new patients coming in as 'randomly' assigned by the MOHLTC (perhaps based on roster size, and of course location).

The capitation formula is broken though, we need a formula that is sensitive to the relative 'overhead' of each patient, over and above age and sex.

Tragically: In an ideal world, the system you describe could work. But, we are stuck with what we have. Capitation's not perfect, but it does work. From the business perspective, the money wasted on the paper chase in administrative costs is mind-boggling. And it doesn't matter what system's put in place. Some docs are always going to cherry-pick.

Sorry to I mistook your views on FP's.

I have been reading with interest the interchange about capitation. When the Ministry was looking southward in the 80's for guidance on the health care system, and HSO's, CHO's and the like came into being, it didn't take many brains to figure out that a system like capitation could not work in an open environment where transience and freedom of choice characterises the patient population's utilization of health care resources. But no one was going to touch the sacred cow of voluntary enrollment. Capitation on the current roster model works best in closed systems like HMO's - which the Ministry seems to have discovered at long last, and is now trying to introduce through the back door by means of a strict rationing system.

I have not kept up with the systems in Alberta, but, in the 90's, they were working with a nominal roster model in some places whereby capitation funds were flowed on a monthly schedule based upon the physician's roster averaged over a 12- or an 18-month period. Much less paper intensive, to be sure, and much better suited to areas of high transient populations.

I suppose from one point of view this would have been the equivalent of 12 or 18 months of FFS revenue, but flowed in an even manner. I do not recall whether there was any adjustment for age and sex, but, presumably that could be managed.

Under that system, it would not matter what patient saw what physician. My guess is, though, that it would not produce the kind of disincentive Tragically envisions, because, face it, there are practitioners who cannot or will not deal with some risk populations. If they cannot, that's one thing, but, if they will not, that's another.

Were we to adopt this kind of approach, negations could be a thing of the past as would the labour-intensive enrollment process.
Rates would have to be age-sex-risk adjusted and therefore competitive, especially to encourage enrollment of risk populations. The need for these kinds of incentives will never die, I think, given human nature, and the example set by rewards for risk in private sector.

If it comes to forcing all the toothpaste to come out of the tube in uniform fashion to be distributed according to some "database state system" as some earlier called it, and choice about referrals is removed for patients (and providers), then, that seems to me to come perilously close to removal of the right of choice, that is, a volunary-enrollment system, in one of its most important aspects. If that conclusion has any merit, then, we are a de facto HMO.

I will share with you some of the benefits of the capitation/salaried system, though.

The principal beneficiary is the patient because one can actually spend a bit of time with the patient, and deal with more than one problem in a visit; the problems are often interconnected, and one problem per visit really does not serve the patient. They also do not have to visit to get a prescription renewal. My own physician causes me to do this (he is in a FHG), and it's a waste of my time. Other practices charge $10 for a telephone renewal.

A second beneficiary of this system is the teaching of students. Because one does not have to see 40 patients a day to survive economically (and just what patients get out of such enforced brief encounters is another matter), one has a bit of time to spend with patient and student alike. That is particularly important if one has clinical clerks who are much more time-intensive than residents. Prior to the introduction of capitation/salary, academic physicians were going broke trying to balance teaching, research, students, and patient care.

A third beneficiary is one's other clinical staff. If the nursing staff or the dietician etc. want to learn along with the clerks and the residents where there is an interesting case, or, if the nursing staff want a bit of time, that can be managed much more easily in the capitation/salaried environment than in the FFS where the pressures can be of quite a different kind.

We have a colleague in Ottawa who has been diagnosed with Altzheimer's. Since we are the POA's for personal care, one of us now will go with her to her appointments with her FP and her neurologist. We met her FP for the first time this week. This practice is a FFS practice in the outskirts of the city in a mall with a number of other related kinds of health care providers. So there are other services to be had on the premises including a lab. A good setup.

The visit would have been kept to 5 minutes if the physician had had her way. It was clear she did not even know our friend as a person although our friend has been a patient for many years. And it was clear that the physician was not comfortable with this patient type.

Two things about this: First, our friend needs more than five minutes, and some attention to medication adjustments which would not have been made were we not there. Second, this physician is perhaps someone who perhaps cannot not be at his/her most effective in dealing with this kind of patient because of the obvious discomfort level (also reported to us by a mutual nurse friend who has accompanied our friend before).

This is becoming a shaggy dog story, but my immediate points are: Flawed as the salaried/capitation model may be, it has its benefits. Second, patients cannot and should not be randomly assigned to providers. Clearly there was no therapeutic relationship established in this case, and that often drives the quality of the application of technical skills.

So, Tragically, marvellous as it might be in theory to be able to ensure noone goes without family physician coverage on a random assignment basis, it can probably only work 50% of the time, given that the sum of all probabilities is 1. That might suit the Ministry, but it will not suit you when your own loved ones are involved.

Now, if you are wondering where I am getting all the time to do this long blurb, it is because I am not getting other things done, and my lunch time just went out the window.

Ciao

" ...colleague in Ottawa who has been diagnosed with Altzheimer's. Since we are the POA's for personal care, one of us now will go with her to her appointments with her FP and her neurologist. "

There aren't enough care providers who can deal with this. Don't fault the FP. It is beyond him.

EKlimek: The state of discomfort extended to the apparent failure to appreciate the primary care needs in relation to her high diabetes risk and her depression. And her Altzheimer's is not so far along that she cannot function at all. The short-term memory is the issue, and the ability to manage easily the routine details of daily life. This patient is still capable of reasonably coherent and meaningful conversation -- although she is deteriorating faster than we could wish.

The point is, there was no therapeutic relationship established over the years and the practitioner was still not relating to the patient, Altzheimer's notwithstanding. The neurologist deals with that.

And the main point was why would we put establishment of the therapeutic relationship at higher risk through a randomized approach to patient-provider assignment than it already may be where choice (as in this case) is still possible?

"why would we put establishment of the therapeutic relationship at higher risk through a randomized approach to patient-provider assignment "

I wouldn't. There are some situations when the mismatch is insurmountable and inappropriately prescriptive.

EKlimek: I am certain you would not. I am less certain that this may not be tried by Central at some point.

Sybil, I hope you got some lunch! Thanks for your thought provoking comments.

"The principal beneficiary is the patient because one can actually spend a bit of time with the patient, and deal with more than one problem in a visit;" Sybil

As much as I agree with this statement and your outline of the beneficiaries of the capitated models, I need to add that the the only beneficiaries are the ones that can access this type of care. While productivity appears to drop in some of these models compared to FFS, I am left to consider what would happen if miraculously all providers suddenly went to capitated models overnight. If this were to occur we would see an exacerbation of the orphan patient problem and the only place left after FFS docs and urgent care clinics go "poof" is the ER.

And please don't tell me that the other providers are going to make a sustainable system because such will just not be the case in the midst of a nursing shortage and even a shortage of PAs (although you've heard me say that I support the concept of PAs working with physicians wholeheartedly).

So we are left with a system that needs to feel its way along in the dark essentially, not changing anything too quickly for fear of bad bumps.

I still say the government is making a huge mistake by trying to eliminate FFS since it definitely has a role in primary care for many patients.

If you really believe that many more layers of providers in primary care is going to save all kinds of money in the long run because patients will be so much healthier then consider that the fast growing demographic is the over 85 year olds and this demographic is also the most expensive compared to younger demographic groups.

So: prevent illness by many layers of providers and tests with expensive pricetags will lead to more patients growing old not necessarily quietly or gracefully and who instead of having their MI will now need hip replacements, knee replacements, cataract surgery and treatments for cancer of many kinds with the additional caveat that cancer is becoming a chronic disease.

There will be no savings to government programs if this is the plan. The upfront costs will be extensive and well as the back end costs.

Of course, if government doesn't plan to bolster its long term care programs and has no plans to strengthen its social programs then perhaps the status quo will only deteriorate marginally.

Please don't misinterpret what I am saying to mean that I don't believe in prevention. I do....on an individual level...but if you think that prevention through multiple layers of providers and screening tests in less productive capitated models is going to save the day then you are mistaken.

Just for the record...

as for the one problem per visit concern....look for my Sept. 23 CMAJ editorial

Realist: I don't think there was anything in my blurb that advocated for layers of care being better care. Nor did I advocate elimination of FFS. I had something to say about the benefits of capitation/salary from the perspective of not having to see 40 or more patients a day instead of the 30 I see now. And, actually, about 40-50 still go through just my practice alone on a daily basis if you count what the primary care nurses do. And about 35% of them are 65 or older.

Thanks very much sybil (and realist) for your thoughtful feedback on capitation, as it is (and may be in the future). So there are (at least) two barriers to an MOH-administered queue system of matching GPs with patients:

- lack of freedom of choice for the patient (and I suppose the FP)

- not enough FPs currently available to service all residents of Ontario

- of the FPs that are available, some (many actually), prefer FFS over capitation as their major source of funding

With respect to freedom of choice, I submit that, in perhaps 95 per cent of the cases, it wouldn't be a problem, as (maybe I'm using rose-colored glasses) the 'silent majority' is easy to get along with. We'd need to support special requests, though, certainly if a physician of one gender is preferred - this would be part of the matching system, but may postpone the 'matching'.

Likewise if one or the other party feels the match isn't appropriate, there would be a protocol to find another match (the link could immediately be broken by either party),

The system would guarantee an immediate match on the first go round, but subsequent rematching could experience delays (an incentive for the patient to make it work the first time).

Of course we need a significant increase in the number of GPs, but I'm under the impression that's coming. What is our current orphan count? 600K? That would imply an increase of 300 to 400 family practs?

And with respect to the third point - the GP 'right to choose' a FFS payment model - I'm afraid that's going to disappear regardless, so might as well bite the bullet now!

And of course we need a system of capitation that puts some weighting on the 'overhead' each patient comes with. Perhaps we could use patient history somehow, identify diabetics, mental health issues, addiction, etc, and pay accordingly.

It could work, but I sense it's a long way off.

Tragically, I think perhaps regulating patient-provider relationships is not practical or practicable if it has to go through iterations with formal procedures and paper to make a change where a match does not occur. It would be no more efficient than the current system where the voting is done with the feet if the patient does not believe the current provider is the provider for him/her. Even in the current climate of relatively restricted family physician supply, this still goes on. It is not uncommon for a young person who is canvassing for a new family physician to request to interview the physician prior to making the commitment. I suppose the reverse is those of our colleagues who do this to patients.

From the conceptual point of view, the idea of the queue can be attractive. And if patients were "stepford" patients, perhaps this could work. But they are not. And the younger generation certainly is not. It has very definite ideas about what it wants.

The Ministry also does not have the information technology to underpin a meaningful information system on patient population characteristics. The kind of technology needed for that would be hugely expensive and sophisticated, even supposing
such a project were feasible. And the realization of such a database scares the living daylights out of me. The implications for manipulation of data for planning ends driven by a political agenda rather than actual health care system needs are staggering.

With the acceptance of population-based health care, and the increasing marginalization of the risk populations to weak to be heard at the polls, we already accept death of our fellow citizens under "friendly fire." At least when this happens in a military exercise, it gets investigated. The deaths from c-difficile and other seriously adverse consequences that may be linked to our failure to fund our system appropriately and orientate it to its true purpose represent your acceptance and mine that people are going to die so the rest of us we can have it free. I feel the need to change that and to fight for that change.

In a population-based approach to health, where practitioner funding and practice is shaped to that end, and driven by a political agenda, we are dealing at the macro-level where everything is conceptual and the people at the grassroots level, like the common soldier, are statistics -- not real to the planners and the politicians. It is a soldier's job, in a way, to be and to become a statistic. It's not mine and it's not yours. We did not make the front line of battle a life choice. And yet, here we are.

This needs to be repeated.

With the acceptance of population-based health care, and the increasing marginalization of the risk populations to weak to be heard at the polls, we already accept death of our fellow citizens under "friendly fire." At least when this happens in a military exercise, it gets investigated. The deaths from c-difficile and other seriously adverse consequences that may be linked to our failure to fund our system appropriately and orientate it to its true purpose represent your acceptance and mine that people are going to die so the rest of us we can have it free. I feel the need to change that and to fight for that change.

In a population-based approach to health, where practitioner funding and practice is shaped to that end, and driven by a political agenda, we are dealing at the macro-level where everything is conceptual and the people at the grassroots level, like the common soldier, are statistics -- not real to the planners and the politicians. It is a soldier's job, in a way, to be and to become a statistic. It's not mine and it's not yours. We did not make the front line of battle a life choice. And yet, here we are.

mfo

Seems you have stopped drinking from the office water cooler. Very good precis. What's the next step?

DrK

I copied that from Sybil because it is so good.

mfo

It is a pansystemic failure where diapers are being horded in nursing homes and patients are treated on stretchers in ER corrodors. The advances that seem to be heralded are those found in primary care or episodic care.

These are so remote from the delivery of acute complex and continuing care that they are in fact disconnected with the daily care of ill patients (or soldiers in Sybil's military comparison).

is there a next step suggestion?

DrK

Central can't go the next step in that that would be to return "control" to the individual. To do that would require a committment to individuals ability to make sound desicions for themselves. Central does not believe in that.

It truly believes that central is here to govern and lead so that most are OK.

The first could be a pooling of some resources and to give each citizen in Ontario a health credit of say 3000.00. You are responsible for all payments for the first 3000 dollars of cost. If you don't consume your 3000 it applies as tax deduction. That puts an incentive on those who pay taxes, not to consume resources unless needed.

For those who don't pay taxes, at year end you can cash in your credit for a cheque worth hald the credit.


There are all sorts of variations, all of which have been discussed but all rejected because, deep down, central doesn't wish to give its power back, and too many are doing too well with a tax bucket filled up each year with 45,000,000,000.00.

We are not going to change this system

mfO, maybe "we" are not going to change the system but I believe the time is coming that population health is going to suffer as more dollars are frittered away in the public health care system through bureacratic waste and through the abuse of a system that is seen to be "free".

Either many more patients are not going to get the care they need in the public system in a timely way or our education system and environment will play second fiddle to health care for splinters and all.

Spreading the icing too thinly just pulls up the cake and makes a big mess...that is where we are at. Something has to give.

"population health is going to suffer as more dollars are frittered away in the public health care system through bureacratic waste and through the abuse of a system that is seen to be "free"

I am unable to rise to such a sweeping conclusion. It begins to resemble political rhetoric in scope and its vague call for change.

There may be bureascratic waste, there may not. That is an implementation problem.

What troubles me is emphasis on episodic and primary care as more meaningful public health care. Putting more into that pot and providing greater access for minor and popular public health disturbances at the cost of underfunding complex continuing acute care sacrifices the most vulnerable.

I admit my bias in this. My profession requires it. Now isn't there a convenant with society, if I am required to provide it, then they must also enable it, not obstruct it?

"I am unable to rise to such a sweeping conclusion. It begins to resemble political rhetoric in scope and its vague call for change."eklimek

Eklimek,
What I'm getting at is that clean water and clean air and a good education will provide significant benefits to population health.
Those groups who want to spend every last dollar our country has on "health care" seem to be missing the point that we have other areas that are important to fund as well.

No sweeping conclusion here, just a reality check. We are coming to some difficult decisions in health care. What do we fund and for whom.....it will become increasingly necessary in our present system to deny vulnerable patients expensive care as is happening now with some cancer patients and some patients with inherited disease. I don't think this is the right approach. Patients shouldn't die because they cannot afford medical care but this is what we will have increasingly in our system of rationing.

Seems we have no limit to the number of times you can come in with your stubbed toe or sliver or sore throat but your meds for Hunter's disease will not be covered. Just doesn't seem right to me....
rhetoric or no rhetoric.

Our public system should not be the "thumbs up thumbs down" program that it is becoming....More private options are needed for those who are willing and able to pay to make more room for more patients in the public system who cannot afford to pay.

Unrealistic you think?

Just look at MRIs.

Realist and EKlimek:

Public Health is a separate pot of money in a separate branch of the Ministry and population health, that is, healthy public policy, is properly within its purview. The degree to which Public Health has been disparaged and savaged from the budget funding point of view in recent years is deplorable. Since the advent of sulpha-base therapies and penicillin and the relative demise of common reportable diseases, Public Health has been thought to be less and less important. Ah, there is nothing like arrogance based upon ignorance...

Primary care, were the truth to be known, has probably never been as effectively organized as it might have been, and has long since been undervalued for the potential it has to participate in an optimal way within the health care system. While it was attractive as a calling for a time, as professional fashion goes, it has fallen into some decline with which the MOHLTC has a good deal to do, so unattractive has the current landscape been made.

The growth and development of primary care's potential should not impinge upon the proper complement of resources for acute care. We are seeing the wages of that, and have done for a fair space of time. But the MOHLTC is hell bent for election to ratchet the cost of the system down in any way it can. So, acute care and primary care will be at each other's throats over the rationed dollar as acute care perceives the growth and development of primary care and public health to be somewhat at its expense. Primary care has, of course, for years thought the reverse was true. And it was.

Noone will disagree with the general principle that each part of the system should be funded to the level appropriate to its requirements. One supposes, though, that there will always be disagreement over what the requirements are, and so, over the level of resources. That's inevitable.

I assume that noone would disgree with the following principles:

1. Everyone eligible should have equal access to health care resources.
2. Everyone who needs it should have first-dollar coverage against catastrophic illness costs.
3. Private sector resources and private money must be allowed to flow into the system.
4. Any introdution of private sector resources or private money into the system cannot be tied to ability to pay and so disadvantage those who cannot.
5. Those who can afford to pay some of their costs should have that choice.
6. The Canada Health Act needs to be revisited.

Have a good week-end, all.